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Ruhe, 2019 Comment on Horowitz, 2019 Tapering of SSRI treatment to mitigate withdrawal symptoms

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Onmyway

https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30182-8/fulltext

 

This just came out as a response to the Horrowitz paper. It is proposing a much more aggressive path to discontinuation than the 10%  rule and has tapering schedules for a number of drugs. Seems like they call their version mini tapering and the 10% reduction micro-tapering. They also seem to be against long holds between tapering. 

 

"This Taskforce does not consider prolonged use of any dosage of these discontinuation steps without further attempts of discontinuation as being rational pharmacotherapy. SNRI=serotonin–norepinephrine reuptake inhibitor."

 

Here is the abstract: 

"In their excellent manuscript, published in The Lancet Psychiatry, Mark Horowitz and David Taylor 1  share their personal view on tapering of SSRI treatment to mitigate antidepressant withdrawal symptoms. In the Netherlands, this topic has been raising debate as well, 2 which urged representatives of the Dutch college of General Practitioners, the Royal Dutch Pharmacists Association, the Dutch Association for Psychiatry, and the patient organisation MIND to develop multidisciplinary recommendations for the discontinuation of SSRIs and serotonin–norepinephrine reuptake inhibitors (SNRIs; appendix pp 1–15). Independent of Horowitz and Taylor,1  but with identical reasoning, we proposed reducing doses of SSRIs or SNRIs hyperbolically, and we also advocated the strategy of mini-tapering (tableappendix pp 3–6)."

 

On a positive note, there seems to be a long term trial of discontinuation of SSRIs in the Netherlands. Details here: https://opera-project.nl/

 

Aug  2000 - July 2003 (ct, 4-6 wk wd) , citalopram 20 mg ,  xanax prn, wellbutrin for a few months (don't remember dates), trazodone prn 

Dec 2004 - July 2018 citalopram 20 mg

Aug 2018 - citalopram 40 mg (self titrated up), occasionally did this in difficult times 

September 2018 - January 2019 tapered citalopram - 40/30/20/10/5 no issues until a week after reaching 0

Feb 2019 0.25 xanax/day, then 0.5/day (3 weeks) over to klonopin 0.25 once a day to manage severe wd

March 6, reinstated citalopram 2.5 mg (liquid), klonopin 0.25 mg for sleep 2-3 times a week

Apr 1st 2.0 mg (liquid), klonopin 0.25 once a week, April  14 , 2019 - citalopram 1.8 mg (liquid), May 8, 2019 - citalopram 1.6 mg (liquid),  July 27, 2019 - citalopram 1.5 mg (liquid),  August 15, 2019 - citalopram 1.35 (liquid)

 

 supplements:  melatonin 1 mg  

 

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kayjaydee

The details are there......but they're in Dutch!


1991 fluoxetine 20mg; Jan 1994 switch to dosulepin 50mg

Jul 1994 switch to clomipramine 50mg

1994 - 2006 clomipramine, doses varying from 50mg to 125mg and back, no major problems decreasing by 12.5mg at a time.

2007 clomipramine 75mg to 0 in 3 weeks, then citalopram 20mg

Jul 2007 switch to dosulepin 50-75mg. Jan 2008 switch to clomipramine 50mg.

2008 to present, clomipramine; to 100mg 2011 following my mother's death

2013 back to 50mg in steps of 12.5mg. 2018 still 50mg, but thinking of reducing - have been OK at 37.5 in the past.

Jan 2019 reduced to 44mg. Feb 2019 to 40mg. Mid-March 2019 to 35mg. July 2019 to 32.5mg. Mid August to 30mg.

Late Sept to 27.5mg. Late Oct. to 25mg. Late May 2020 to 22.5mg. Late June to 20.5mg. Early Aug to 18.4mg.

 

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Onmyway
1 minute ago, kayjaydee said:

The details are there......but they're in Dutch!

Google translate was decent (it gave me the option on the page as I opened!) 

 


Aug  2000 - July 2003 (ct, 4-6 wk wd) , citalopram 20 mg ,  xanax prn, wellbutrin for a few months (don't remember dates), trazodone prn 

Dec 2004 - July 2018 citalopram 20 mg

Aug 2018 - citalopram 40 mg (self titrated up), occasionally did this in difficult times 

September 2018 - January 2019 tapered citalopram - 40/30/20/10/5 no issues until a week after reaching 0

Feb 2019 0.25 xanax/day, then 0.5/day (3 weeks) over to klonopin 0.25 once a day to manage severe wd

March 6, reinstated citalopram 2.5 mg (liquid), klonopin 0.25 mg for sleep 2-3 times a week

Apr 1st 2.0 mg (liquid), klonopin 0.25 once a week, April  14 , 2019 - citalopram 1.8 mg (liquid), May 8, 2019 - citalopram 1.6 mg (liquid),  July 27, 2019 - citalopram 1.5 mg (liquid),  August 15, 2019 - citalopram 1.35 (liquid)

 

 supplements:  melatonin 1 mg  

 

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kayjaydee

I'm failing to find the translation....but never mind, it was only an idle thought to see what it said rather than rely on summaries. I plan to continue with 10% reduction anyway.


1991 fluoxetine 20mg; Jan 1994 switch to dosulepin 50mg

Jul 1994 switch to clomipramine 50mg

1994 - 2006 clomipramine, doses varying from 50mg to 125mg and back, no major problems decreasing by 12.5mg at a time.

2007 clomipramine 75mg to 0 in 3 weeks, then citalopram 20mg

Jul 2007 switch to dosulepin 50-75mg. Jan 2008 switch to clomipramine 50mg.

2008 to present, clomipramine; to 100mg 2011 following my mother's death

2013 back to 50mg in steps of 12.5mg. 2018 still 50mg, but thinking of reducing - have been OK at 37.5 in the past.

Jan 2019 reduced to 44mg. Feb 2019 to 40mg. Mid-March 2019 to 35mg. July 2019 to 32.5mg. Mid August to 30mg.

Late Sept to 27.5mg. Late Oct. to 25mg. Late May 2020 to 22.5mg. Late June to 20.5mg. Early Aug to 18.4mg.

 

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Onmyway

Hi Kayjaydee, I think I misunderstood.

The article itself is in English and the full text is available incl. their proposed tapering schedules. It's just a letter. The Dutch study description is in Dutch but there are no results from it yet, it just talks about the task force and the study design. I think the study will be 2 years+.  This is with Google Translate: 

https://opera-project.nl/

Target

With the OPERA study we want to get more clarity about the reduction of antidepressants. The central question is: does it matter whether you stop taking antidepressants sooner or later after recovery from depression?

Study design

Approximately 2,000 people with depression who have recently started taking antidepressants identify who is recovering. Four hundred recovered patients will be phasing out their antidepressants within a one-year period. Participants are randomly divided into two groups by means of a draw: the early or the later finishing group. After the withdrawal period, the antidepressants are replaced by a placebo pill. Both the doctor and the patient do not know at what time the reduction will start. During and after dismantling, a check is made to see whether symptoms remain away, and how it is going to affect the quality of life, the functioning and the severity of psychological and physical symptoms (side effects, withdrawal symptoms). These outcome measures are (largely online) measured at 10 moments during 2 years after the draw.

Performance

This national research is carried out at general practice and mental healthcare institutions from a consortium of university medical centers throughout the Netherlands (Amsterdam UMC, UMCG, Radboud UMC, Erasmus MC, LUMC). It is also supported by patient organizations and professional organizations (Depression Association, NHG, NVvP, NEDKAD, KNMP, NIVEL). The knowledge and the results of this study about phasing out with antidepressants can be applied in practice.

Read here  the press release about the OPERA project. For more information you can contact the project coordinators Dr. Karlijn Joling (k.joling@vumc.nl) or Dr. Mariska Bot (m.bot@vumc.nl).

 

 

 


Aug  2000 - July 2003 (ct, 4-6 wk wd) , citalopram 20 mg ,  xanax prn, wellbutrin for a few months (don't remember dates), trazodone prn 

Dec 2004 - July 2018 citalopram 20 mg

Aug 2018 - citalopram 40 mg (self titrated up), occasionally did this in difficult times 

September 2018 - January 2019 tapered citalopram - 40/30/20/10/5 no issues until a week after reaching 0

Feb 2019 0.25 xanax/day, then 0.5/day (3 weeks) over to klonopin 0.25 once a day to manage severe wd

March 6, reinstated citalopram 2.5 mg (liquid), klonopin 0.25 mg for sleep 2-3 times a week

Apr 1st 2.0 mg (liquid), klonopin 0.25 once a week, April  14 , 2019 - citalopram 1.8 mg (liquid), May 8, 2019 - citalopram 1.6 mg (liquid),  July 27, 2019 - citalopram 1.5 mg (liquid),  August 15, 2019 - citalopram 1.35 (liquid)

 

 supplements:  melatonin 1 mg  

 

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kayjaydee

Interesting that they're doing the study double-blind - that would reduce effects like worrying about feeling worse because you know you're on a lower dose.


1991 fluoxetine 20mg; Jan 1994 switch to dosulepin 50mg

Jul 1994 switch to clomipramine 50mg

1994 - 2006 clomipramine, doses varying from 50mg to 125mg and back, no major problems decreasing by 12.5mg at a time.

2007 clomipramine 75mg to 0 in 3 weeks, then citalopram 20mg

Jul 2007 switch to dosulepin 50-75mg. Jan 2008 switch to clomipramine 50mg.

2008 to present, clomipramine; to 100mg 2011 following my mother's death

2013 back to 50mg in steps of 12.5mg. 2018 still 50mg, but thinking of reducing - have been OK at 37.5 in the past.

Jan 2019 reduced to 44mg. Feb 2019 to 40mg. Mid-March 2019 to 35mg. July 2019 to 32.5mg. Mid August to 30mg.

Late Sept to 27.5mg. Late Oct. to 25mg. Late May 2020 to 22.5mg. Late June to 20.5mg. Early Aug to 18.4mg.

 

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Altostrata

Please read this before starting any more topics in Journals

 

A page in English about the OPERA study https://psychiatryamsterdam.nl/project/opera/


This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

All postings © copyrighted.

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kayjaydee

Thanks, Altostrata, I'll check that out.


1991 fluoxetine 20mg; Jan 1994 switch to dosulepin 50mg

Jul 1994 switch to clomipramine 50mg

1994 - 2006 clomipramine, doses varying from 50mg to 125mg and back, no major problems decreasing by 12.5mg at a time.

2007 clomipramine 75mg to 0 in 3 weeks, then citalopram 20mg

Jul 2007 switch to dosulepin 50-75mg. Jan 2008 switch to clomipramine 50mg.

2008 to present, clomipramine; to 100mg 2011 following my mother's death

2013 back to 50mg in steps of 12.5mg. 2018 still 50mg, but thinking of reducing - have been OK at 37.5 in the past.

Jan 2019 reduced to 44mg. Feb 2019 to 40mg. Mid-March 2019 to 35mg. July 2019 to 32.5mg. Mid August to 30mg.

Late Sept to 27.5mg. Late Oct. to 25mg. Late May 2020 to 22.5mg. Late June to 20.5mg. Early Aug to 18.4mg.

 

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